Development and validation of the MosquitoWise survey to assess perceptions towards mosquitoes and mosquito-borne viruses in Europe

Due to climate change and the expanding geographical ranges of key mosquito species, several mosquito-borne viruses (MBVs) have recently emerged in Europe. Understanding people’s perceptions and behaviours towards these viruses and the mosquitoes capable of transmitting them is crucial for implementing effective prevention measures and targeted communication campaigns. However, there is currently no appropriate validated survey for European populations to assess this. This study developed and validated a standardized survey, based on the Health Belief Model (HBM), to assess perceptions of mosquitoes and MBVs among Europe’s residents. The survey was distributed online to United Kingdom (UK), Dutch and Spanish participants through panel providers. Survey validity and reliability were tested using confirmatory factor analysis (CFA) and Cronbach’s alpha. The optimised survey was completed by 336 UK, 438 Dutch and 475 Spanish residents, respectively, and the HBM items passed our validity and reliability testing in all three countries. The final survey has 57 questions, including 19 validated HBM items, and questions to assess demographic characteristics, knowledge, prevention measures and behavioural determinants. Our MosquitoWise survey bridges researchers' understandings of European residents’ perceptions and knowledge as a first step to improve preventive behaviour towards mosquitoes and MBVs and guide prevention and communication initiatives.


Methods
The development and validation of this MosquitoWise survey were based on previously published guidelines on this process 26 .Using the methods described by Boateng et al., we address the development of questions, hereafter called items, and the survey's validity in three languages.Our study methods are described in detail below, divided into three main parts: survey development and translation, data collection using a representative population panel to gather participants' survey responses, and data analysis for validity assessment of the survey using participant responses (Fig. 1).

Target populations
We developed the survey to capture perceptions, knowledge and behaviour in European populations with different mosquito abundances, as well as different mosquito-borne viral prevalence The survey was distributed among the general populations, aged 18 and over, of three countries: the United Kingdom, the Netherlands and Spain 22,[27][28][29] .

Model selection and item generation
The survey was structured based on the HBM, which matches this study's research aims 23,24 .Our survey included the following HBM constructs: Perceived Susceptibility (SUS), Perceived Severity (SEV), Perceived Barriers (BAR), Perceived Benefits (BEN), Self-Efficacy (SE) and Cues to Action (CUE) (Fig. 2).Based on these constructs, items were developed in collaboration with several virology, entomology and behavioural experts.Items were measured with a 7-point Likert scale, which is commonly used for participants to rate their level of agreement or disagreement with a statement 30 .Each Item is rated as 1 (Strongly Disagree), 2 (Disagree), 3 (Somewhat Disagree), 4 (Neutral), 5 (Somewhat Agree), 6 (Agree) And 7 (Strongly Agree).Additional items (specifically on knowledge, prevention measure use, and demographics) were included to gauge behaviour.Two control items (such as "Please select 'Somewhat Disagree' as your answer choice") were added to check if participants completed the survey with authentic responses 31 .The survey was developed in English using B1 language to make items understandable for the general public 32 .

Survey evaluation (expert reviews and cognitive interviews)
The first survey draft's contents were systematically evaluated by four experts (medical entomologist, risk communication/questionnaire development specialist and native English speaking science communicators) using a rubric with the following criteria: clarity, wording, responses, appropriateness, balance, measure of constructs and survey aims 33,34 .Changes to the survey were made according to the experts' scores and comments.
To test the survey within a target population, cognitive interviews with five United Kingdom (UK) residents were conducted through online videoconferencing, following existing guidelines 33 .The participants consented to participate in the study and to being recorded during the exercise.During the cognitive interviews, participants read items aloud and verbally narrated what they were thinking while selecting their answers.Researchers (AA and PdB) and participants flagged any items that seemed confusing or took long to answer.Flagged items, item wording and language and any other changes were discussed after completing the survey.Changes were made to the survey accordingly.

Data collection
To assess the survey's validity within our target populations, data was collected using heterogeneous, representative samples (based on age and sex) from the general populations of the United Kingdom, the Netherlands, and Spain aged 18 and over.Participants were recruited through two panels: Prolific Academic for UK residents and Bilendi for Dutch and Spanish residents 35,36 .Participants were directed from the panel environment to the survey in LimeSurvey.In LimeSurvey, participants were informed about the study aim, their right to withdraw from the study, and assured their data would be stored anonymously.By continuing with the survey, participants gave their informed consent.We included participants who met the following criteria: resident of the respective country (UK, the Netherlands or Spain) and aged ≥ 18 years.The first version of the survey (Fig. 1, Survey Version 1) was completed by a sample of UK participants between October 4 and October 8, 2021 (UK Sample 1).Following the initial validity analysis, the survey was refined (Fig. 2, Survey Version 2) and distributed again to a second sample of UK citizens through Prolific from

Data analysis
Exclusion criteria and descriptive statistics Before the data was analysed, exclusion criteria of participants were applied.Participants were excluded if (a) they incorrectly answered both control items (located in different parts of the survey), (b) they did not complete the survey in the appropriate time limit (2-25 min) or (c) they did not complete the full survey.Descriptive statistics were performed for participant characteristics and item response frequencies for the HBM items using R (version 4.2.2, by RStudio version 2022.12.0 + 335 for Mac and 2022.07.1 + 554 for Windows; Posit Software, PBC, Boston, MA).

Confirmatory factor analysis and reliability testing
Survey validation was primarily completed using confirmatory factor analysis (CFA), performed using the lavaan package in R 37 .CFA tests how item response patterns relate to each other.By analysing response patterns, CFA can determine if items fit within the designed HBM constructs and if these items group together to measure each respective construct.To ensure the order of the HBM items in the survey would not influence the participants' item response patterns, the items' order was randomized within the online survey environment (LimeSurvey).Since multiple items measure the same construct and the item responses were categorical, we used a Weighted Least Squares with Mean and Variance adjustment estimator, referred to as WLS(MV) estimator 38,39 .
The goodness of fit of the HBM was assessed for each survey version (using participants' responses) based on the following commonly used fit indices for CFA: chi-square test (χ 2 ), root mean square error of approximation (RMSEA) ≤ 0.06 and comparative fit index (CFI) ≥ 0.95 [40][41][42] .Since chi-square tests are sensitive to sample size, we use the ratio of the chi-square statistic to the degrees of freedom (χ 2 /df) to assess fitness, with a ratio of ≤ 2 indicating a good fit 43,44 .Furthermore, to aid item selection and to improve model fit, item factor loadings where assessed.Factor loadings show the variance explained by an item within the corresponding construct (also called a factor).Items with a low factor loading (< 0.3) with their corresponding constructs do not substantially contribute to explaining variance within that construct 45 .To improve the model fit parameters, items were removed from the model and then from the survey when: (a) the factor loading with the corresponding construct was less than 0.3 or (b) when modification indices indicated a better model fit if an item were to be removed 42,46 .To evaluate each construct's and the survey's reliability (consistency of the data), we used Cronbach's alpha (α).Cronbach's alpha is a measure of internal consistency and functions as an index of reliability 26 .Alpha values of 0.6-0.7 were considered acceptable, and values above 0.7 were considered good 47 .

HBM scores
Mean scores for each HBM construct were calculated using the 7-point Likert-scale, where "Strongly Agree" equated to 7 points and "Strongly Disagree" was worth 1 point.However, for Perceived Barriers, answers were inversed, so a higher Perceived Barriers mean score indicates there are no perceived barriers for prevention measure use and, thus, a higher intent to engage in preventive behaviour.All mean construct scores were summed into a final HBM score (with a score range of 6 to 42).A low HBM score reflects a low intent to show preventive behaviour, and a high score reveals a high intent to show preventive behaviour.

Ethical statements
All methods were carried out in accordance with relevant guidelines and regulations for human subjects' research, including European ethics requirements and best practices.Survey respondents were all at least 18 years old, they provided informed consent prior to participating, and no personal information was collected from them.The research protocol was submitted to the Medical Ethics Committee at Erasmus University Medical Center prior to implementation, and that Committee determined that the methods were not subject to the Dutch Medical Research Involving Human Subject's Act and could therefore be carried out without further review (Ref.MEC-2021-0586 dated 21 September 2021).

Survey evaluation (expert reviews and cognitive interviews)
After the HBM was selected as the survey model, items were generated, and a first survey draft was created containing 64 items (Fig. 1).Survey evaluation through experts' rubric evaluations and cognitive interviews resulted in removing 15 items.Suggestions were mostly directed at avoiding negative wording, specifying items to ensure correct item interpretation and clarifying by adding pictures.Modifications resulted in Survey Version 1 with a total of 57 items, including 25 HBM items (Figs. 1 and 2, Survey Version 1).

Participant characteristics
After applying the exclusion criteria, the final number of participants were 513 and 338 for the United Kingdom (first and second sample) and 438 and 475 for the Netherlands and Spain, respectively.Table 1 shows the demographic characteristics of the included participants for each data collection sample and the national median age 48 .The participants in the Netherlands sample had the same median age as that of the Dutch population aged 18 and over.The gender distribution of the Netherlands sample matches the national gender distribution for this age range (Male 49%, Female 51%) 48 .The Spanish national median age for residents aged 18 and over is one year higher than the median age in the Spain sample.The gender distribution in the Spain sample shows slightly more male participants compared to the national distribution for this age range (Male 48.3%, Female 51.7%).The UK national median age for residents aged 18 and over is three years higher than the median age of each of the UK samples.The gender distribution in the UK sample shows a slightly lower proportion of male participants compared to the national distribution for this age range 48 .

Confirmatory factor analysis and reliability testing
The validity of Survey Version 1 was assessed by performing CFA to assess if the designed items fit the respective HBM constructs with the item responses collected from the UK Sample 1 (n = 513).Model A (Table 2) showed that item responses did not fit the constructs, as factor loadings were too low for several items.Item removal to optimize the model fit by assessing multiple models resulted in model F (Table 2), which showed acceptable fit indices (χ 2 /df = 2.18, RMSEA = 0.048 and CFI = 0.931).Additionally, Model F shows acceptable reliability (α = 0.69).Additional items were created and some rephrased based on factor loadings (Supplementary Table 1) and item response frequencies (Supplementary Fig. 1).The modified survey resulted in 22 HBM items (Supplementary Material, Full Surveys).
The validity of Survey Version 2 was assessed by performing CFA with the item responses from UK population sample 2 (n = 338) (Table 2, Model G).Model G revealed the data did not fit since the thresholds were not met.After closer assessment, Model G showed that SEVrecover did not contribute to Perceived Severity (factor loading = − 0.059) (Table 3) and was removed, resulting in Model H (Table 2).Model H showed improved fit  www.nature.com/scientificreports/indices, but the data did not fit the five-construct structure (Table 2).Factor loading revealed an underlying latent trait within the combined Perceived Barriers and Benefits construct, leading to a new six-construct model structure in Model I (Table 2).This modification, together with the removal of two additional items (BBcloth and SEpmuse) due to low factor loadings, resulted in the new six-construct, 19-item Model K UK .Model K UK showed good model fit (χ 2 /df = 1.09,RMSEA = 0.016 and CFI = 0.993) (Table 2), factor loadings (Table 3) and overall scale reliability (α = 0.73).All constructs of the final Model K UK showed acceptable and good reliability, except for Perceived Benefits (α = 0.46) (Table 4).Since all other measurement properties, including the factor loadings of the Perceived Benefits, indicated a good fit, Model K UK was accepted.Survey Version 3 was comprised of these 19 HBM items from Model K UK , which were translated to Dutch (Model K NL ) and Spanish (Model K ES) (Fig. 2, Survey Version 3).The validity of Dutch Survey Version 3 was assessed by performing CFA with the item responses from the Dutch sample (n = 438).CFA confirmed an acceptable fit of Model K NL (Table 2), and all factor loadings were above 0.3 (Table 4).Constructs showed acceptable or good reliability except for Perceived Susceptibility (α = 0.57) (Table 4).The overall reliability of the HBM survey was also good (α = 0.76).
By performing CFA with the item responses from the Spanish sample (n = 475), the validity of the Spanish Survey Version 3 was also assessed.CFA indicated a good fit of Model K ES (Table 2), and all factor loadings were above 0.3 (Table 4).Each construct showed acceptable or good reliability (Table 4).Reliability of the full Spanish HBM scale was also good with a Cronbach's alpha coefficient of 0.79.

Final survey
The final Survey Version 3 has 57 items, which includes the 19 validated HBM items, and is available in three languages (English, Dutch and Spanish) (Supplementary Material, Full Surveys).Table 5 shows all the HBM items in the final survey version.The additional items (not the validated HBM items) are directed at identifying potential characteristics that might influence the behaviour as measured by the HBM items and include: Predictor items (including direct surroundings and housing, travelling, mosquito nuisance and information sources) (n = 26), knowledge items (mosquito biting times, breeding sites, MBV, and MBV transmission routes) (n = 4), prevention measure use (which prevention measures used and reasons for using or not using prevention measures) (n = 3), perceived responsibility (n = 3) and the control items (n = 2).www.nature.com/scientificreports/

HBM scores
Using the responses to the 19 validated HBM items, construct mean scores and HBM sum scores were calculated for each participant per country (Table 6).

Discussion
This study describes the development and validation of an HBM-based survey to assess perceptions of mosquito bites and MBVs in European regions.We developed the MosquitoWise survey, the first validated Europe-wide applicable tool to measure these constructs among Europe's residents.With the (expected) expanding range of mosquito-borne diseases, this survey can aid in understanding and creating data-driven decisions to alter populations' behaviours to prevent mosquito-borne disease transmission.The development of the MosquitoWise survey makes several contributions to the currently available European surveys.Previously developed surveys have tended to be related to a specific mosquito species or MBV, rather than a broader scope of understanding behaviour towards mosquitoes and MBVs.Additionally, most surveys used in European studies are not validated, are Knowledge, Attitudes and Practices (KAP) surveys or are tailored to a certain population, rather than the general public 17,18,21,49,50 .We identified one Italian validated survey, created specifically to measure knowledge, attitude and behaviours towards Zika in the general population.While the necessary steps were taken to validate this survey, the survey was validated using responses from medical doctors, who were not the intended target population 51 .Although this gives some insight into the survey's internal consistency, the survey might perform differently in the intended population.Since our survey's target population is the public, we ensured that validity analysis was based on responses from the general population in the three targeted countries.This helps make the MosquitoWise survey particularly useful for research in Europe's shifting MBV landscape.
This study has shown that the analysis of content and constructs have clearly improved the survey's performance as measured by the confirmatory factor analyses and internal consistency reliability testing.This is exemplified by the restructuring of the construct Perceived Barriers and Benefits into two separate constructs.While the first and second survey versions followed the combined structure, factor loadings for Survey Version 2 indicated that the survey would perform better with Perceived Barriers and Perceived Benefits as separate constructs.This change improved the performance of the survey, as assessed by the fit indices of the confirmatory factor analyses performed for the different countries, resulting in the final version of this survey (Fig. 2, Survey Version 3).While the reliability of most constructs was between 0.6 and 0.81, Cronbach's alpha for Perceived Susceptibility in the Dutch survey was lower but very close to 0.6.The Cronbach's alpha for Perceived Benefits is below 0.5 for the English version of the survey.The number of items in a construct influences the Cronbach alpha, so constructs with a lower number of items more often show lower values 47 .Increasing the number of items could, therefore, be a solution.However, the survey length is also an important consideration together with the other measurement properties of the items.Further research in the United Kingdom could help improve the www.nature.com/scientificreports/performance of the construct in this country.Since the overall reliabilities for the survey scales for the United Kingdom, the Netherlands and Spain are within a good range, we accept the reliability of the surveys.Some limitations of this study need to be acknowledged.We aimed to assess the surveys validity and reliability using a representative population sample.The panels used in this survey were chosen as effective ways to reach participants, but using survey panels has several limitations.First, representativeness can never fully be achieved within a panel population.Although the median ages and gender distribution of our sampled populations and the national median ages and gender distributions are closely related, other non-corrected population characteristics might show under or overrepresentation 52 .Furthermore, panel members are usually people who already have an interest in completing surveys or join the panel for incentives.Thus, their responses could be influenced by either of these factors, a phenomenon known as panel conditioning 53 .We tried to account for this phenomenon by selecting panels created using probabilistic recruitment, meaning the panel provider randomly invites people from the general population to become a panellist to reduce the effects of panel conditioning 54 .www.nature.com/scientificreports/Lastly, our study may have been subject to recall bias, as participants were asked to report their perceptions and behaviour during mosquito season.We attempted to minimize recall bias by distributing the survey during peak mosquito season months (July and August).However, this was not possible for data collection in the UK.Data collection for Sample 1 took place in April (beginning of mosquito season) and Sample 2 in October (end of mosquito season) 55,56 .Nevertheless, we expect potential recall bias effects to be small, since the period (mosquito season) was clearly specified in each item where this was relevant and mosquito seasonality greatly differs by region 57 .
Despite these limitations, having a validated survey establishes a standard for measurement by ensuring that items are clear, well-understood and measure the intended outcome in the target population.Already having a standard in place reduces time needed to create a survey, enhancing efficiency and consistency.This survey has undergone expert reviewing, pre-testing and has been tested in the target population four times (Fig. 1), diminishing the likelihood of measurement errors and improving data accuracy and reliability of responses.
After careful selection of items and a comprehensive validation process, the MosquitoWise survey is ready to use in Europe.Aside from the survey's 19 core HBM items, which are validated and cannot be changed without revalidating the tool, the knowledge and demographic questions can be removed, added or adjusted to better suit researchers' aims and local situations.Thus, the tool is adaptable and versatile by adding complementary potential background variables that may influence or predict the measured behaviour or knowledge based on specific goals.Not only can this survey be adapted by adding demographic and knowledge questions, but it can also be focused on specific mosquito species or MBVs.While this modification would require revalidating the adjusted survey, the items' phrasal structure allows for this easy change, saving time in survey development.For example, the word "mosquito" in the item 'The likelihood of being bitten by a mosquito in my country of residence is high' can easily be replaced with 'tiger mosquito' , or any other species, keeping the exact same structure of the item while focusing on a specific mosquito species.Similarly, 'Getting sick with a mosquito-borne virus may result in hospitalisation' can be altered to a specific MBV like Zika or dengue virus.
Furthermore, since this tool is validated and is available in English, Dutch and Spanish, comparing survey data from countries with a situational background is possible and can provide insight into health behaviours.To ensure that multiple countries' data can be compared, we suggest sampling populations at similar time points (especially during mosquito season) and assessing measurement invariance between countries 58 .These results can be used to optimize preparedness policies and communication to the public.The use of this tool at multiple time points can provide insight on behaviour change over time, by measuring the effects and evaluation of communication campaigns, for instance.This can be especially useful considering situational changes resulting in increasing MBV exposure and risk.Combining the survey with entomological or serological research provides further options to quantify effects of residents' knowledge and preventative behaviours on matters such as larvae presence in backyards or MBV exposure in populations 20,21,59,60 .
With environments changing and becoming more suitable for mosquito expansion, understanding people's perceptions is crucial to prevent invasive mosquito species establishment and the potential for disease transmission.Thus, recognizing this relationship early can serve as an effective method for successful behavioural interventions in outbreak prevention and management.Our MosquitoWise survey fills a clear gap in knowledge, not only on a national scale, but on a continental one.

Figure 1 .
Figure 1.Complete overview and timeline of development, translations, data collection and data analysis for validity assessment of the English, Dutch and Spanish survey versions.

Figure 2 .
Figure 2. Overview of item codes of all three survey versions.Each code represents one item in the surveys.All the Health Belief Model items follow a 7-point Likert scale.UK United Kingdom, SUS Perceived Susceptibility, SEV Perceived Severity, SE Self-Efficacy, CUE Cues to Action, BB Perceived Barriers and Benefits (combined), BEN Perceived Benefits, BAR Perceived Barriers, KN Knowledge.
April 11 to April 14, 2022 (UK Sample 2).Participants in the second sample were asked if they had completed the survey in October and were excluded if they answered yes.To validate surveys in Spanish and Dutch, the translated surveys (Fig.2, Survey Version 3) were distributed to participants in Spain and the Netherlands.Data was collected in three waves to ensure an even distribution of participants over the summer of 2022.Wave 1 was from July 19 to July 31, wave 2 was from August 1 to August 31 and wave 3 was from September 1 to September 30.

Table 1 .
Characteristics of participants from countries of survey distribution.UK1 United Kingdom Sample 1, UK2 United Kingdom Sample 2, NL Netherlands, ES Spain.a National median age and percent male for residents 18 years and older calculated from Eurostat population data from 2022 (Netherlands and Spain) and 2019 (UK).

Table 2 .
Confirmatory factor analysis and reliability test results for the item responses from samples in the United Kingdom, the Netherlands, and Spain.χ 2 Chi-square value.rmsearoot mean square error of approximation.CFI Comparative Fit Index, α Cronbach's alpha, UK United Kingdom, NL Netherlands, ES Spain, EN English.*Indicates a nonsignificant P value above 0.05.Values were considered good when χ 2 /df ≤ 2, RMSEA ≤ 0.06 and CFI ≥ 0.95.Cronbach Alpha values of 0.6-0.7 were considered acceptable, and values above 0.7 were considered good.Sample (

Table 3 .
Factor loadings results after distribution of Survey Version 2 in the United Kingdom (Sample 2).Items with factor loadings < 0.3 were removed from the survey.Models G and H have five HBM constructs.Models I, J and K have six HBM constructs since Perceived Barriers and Perceived Benefits have been separated into two constructs.

Table 4 .
Factor loadings and construct reliability results for the final Health Belief Model items (Model K) for the United Kingdom, the Netherlands and Spain.EN United Kingdom, NL Netherlands, ES Spain, α Cronbach's alpha coefficient.

Table 5 .
Survey Version 3, the Health Belief Model items in English, Dutch and Spanish.